Laparoscopic Nissen Fundoplication for Symptomatic Recurrence After Endoscopic Fundoplication with the Esophyxr Device

Vic Velanovich, MD. Henry Ford Hospital

Background: Endoscopic fundoplication using the EsophyxR is becoming increasingly used in the surgical treatment of selected patients with gastroesophageal reflux disease (GERD). Although the overall success rate is good, there have been reported short- and long-term recurrences of GERD-related symptoms. This video demonstrated the anatomic consequences of endoscopic fundoplication and its effect on a subsequent laparoscopic Nissen Fundoplication.

Case Report: The patient is a 60 year old female who have typical symptoms of GERD, with a small hiatal hernia as demonstrated by upper endoscopy, esophageal manometry demonstrated a hypotensive lower esophageal sphincter pressure and 24 hour esophageal pH monitoring demonstrating pathologic reflux. She underwent the Total Incisionaless Fundoplication (TIF)-II technique using the Mark-II Esophyx device. Her postoperative esophagogram showed an excellent partial fundoplication. She had good symptom relief for six months, and then developed recurrent symptoms. Repeat endoscopy appeared to demonstrate a good valve, but 24 hour pH monitoring demonstrated pathologic reflux.

Main Operative Finding: The hiatal hernia was present, with no reduction whatsoever. The H-fasteners were extruded from the esophagus, but still attached to the angle of His. Scarring was limited to the region of apposition of the angle of His to the esophagus. Overall, operative difficulty was not greatly increased.

Conclusion: Performance of a laparoscopic Nissen fundoplication is not greatly hindered by a prior endoscopic fundoplication with the Esophyx device. At least in this case, the hiatal hernia was not reduced. Scarring appears to be limited to where the H-fasteners pass from the esophagus to the stomach.